Perimenopause heavy bleeding: Causes, clots, & when to worry

Is heavy bleeding normal in perimenopause?

The short answer is that while it isn’t ‘normal,’ it is a common symptom. Many women experience heavy periods in perimenopause due to expected hormonal fluctuations that occur during this life transition. During perimenopause, rising and falling hormone levels often mean you stop ovulating regularly. Without ovulation, the uterine lining continues to build up under the influence of estrogen without being transformed by progesterone. This buildup is what causes the heavy or prolonged bleeding common during this transition.

If your blood flow is rapid and significant, accompanied by dizziness, rapid heart rate, and shortness of breath, it may be a sign of a hemorrhage, and you should seek medical attention immediately.

How to measure “heaviness” of flow

One in five women experiences heavy menstrual bleeding, but it can be challenging to determine what blood flow is “heavy” and what is “normal”. Clinically, more than 80 ml blood loss is considered heavy menstrual bleeding, but what does that look like in the real world? 

To start, it could be soaking through protection within an hour. With regular menstrual bleeding, it should take between two to eight hours to soak through a pad or tampon, depending on the absorption level, so changing pads every hour is considered heavier than average bleeding. 

Secondly, having to wake up throughout the night to change your pad or tampon is another sign of heavy menstrual bleeding. Finally, if you use double protection and that’s still not enough, your period would be defined as “heavy”. 

Signs of “flooding” and blood clots

Have you ever noticed a sudden gush of blood when you’re on your period that happens without warning? This “flooding” can be embarrassing, especially if it happens when you’re out with friends, at work, or exercising. There are a few reasons why you may experience “flooding” in perimenopause, including if you have uterine polyps, uterine fibroids, or other medical conditions. 

Uterine polyps grow on the inner wall of your uterus. Uterine fibroids are noncancerous tumors in the uterine wall that can cause heavy bleeding, trouble urinating, and fertility issues. 

Another common occurrence during perimenopause is a heavy period with clots. While they can be unnerving to see, not all blood clots are dangerous, so knowing how to differentiate them is important. 

What do dangerous clots look like?

Looking down and seeing a blood clot can be alarming, especially if it’s large. However, blood clots are normal during your period. If you have dark red clots that are dime-sized or below, there’s typically nothing to worry about. However, if you see quarter-sized clots to golf ball sized clots or larger, it could indicate a bigger issue. 

While there are numerous possible reasons you may have larger clots, the most common include uterine fibroids, polyps, and adenomyosis. Clotting with heavy periods in perimenopause can also be caused by the hormonal imbalance associated with the transition, so it’s a good idea to make a GP appointment where your doctor can perform a pelvic exam and look for underlying issues. 

Why is this happening?

As we’ve already mentioned, during perimenopause, there are times when estrogen levels in the luteal phase rise significantly higher than they typically did in the past. Simultaneously, progesterone decreases, causing longer cycles where the uterine lining has more time to grow. This thick endometrial lining results in heavier bleeding when it sheds, causing excessive blood loss. 

But heavy bleeding in perimenopause isn’t always due to high estrogen and low progesterone – there are conditions that cause it as well. Endometrial hyperplasia, where the uterine lining is too thick, uterine fibroids, polyps, thyroid issues, blood clotting issues could also be responsible. 

Hormonal chaos vs. medical red flags

Distinguishing between hormonal causes of heavy bleeding during perimenopause and structural and clotting issues can be challenging. Understanding the symptoms can help you better understand whether you should talk to your doctor. Below is a quick glance table of common symptoms associated with uterine fibroids, polyps, and adenomyosis.

Diagnosis: How to talk to your doctor

Advocating for your health is essential to receiving a diagnosis and treatment plan for heavy bleeding during menopause. Unfortunately, many patients are dismissed when they bring up concerns to their doctor, which is why keeping a symptoms diary is so important. Having comprehensive records for your medical history makes it easier to spot patterns and validate your claims. The Hormona app is the premier cycle tracking tool, making it easy to input symptoms and log important information for your doctor. For example, instead of simply saying you’re having heavy periods, you can show your doctor your Hormona logs, stating, “I soaked 12 pads on Tuesday and had three days of clotting.” That information allows your doctor to get a better picture of what is going on with your body and develop a treatment plan accordingly. The Hormona app also uses AI forecasting to help predict heavy bleeding days so you can prepare in advance. It’s the ultimate tool for gathering evidence for your doctor and putting you in control of your health journey.

When to see a doctor immediately

Knowing the difference between heavy but unconcerning and dangerous bleeding is essential for your health. If you have any of the following symptoms with heavy bleeding, you should go to the emergency room immediately. 

• Shortness of breath
• Feeling dizzy or weak
• Having large clots
• Feeling faint
• Soaking through 1 pad per hour
• Severe cramping

Medical treatment options for heavy bleeding

While heavy bleeding during perimenopause can be disruptive to your daily life, the good news is that there are treatment options. Here are the most common medical treatments that can help you find relief.

Hormonal IUD

The hormonal IUD with 52 mg of levonorgestrel is an excellent option for women who need contraception while lightening menstrual bleeding. It inserts into the uterus and doesn’t require you to take daily pills, making it great for women who worry about forgetting their contraception.

Hormonal birth control 

If you’re uncomfortable with using an IUD, traditional hormonal birth control is also an effective medical treatment for heavy bleeding during perimenopause. Both options help stabilize fluctuating hormones, thinning the uterine lining and reducing blood loss. Oral contraceptive options are either estrogen and progesterone combined or progesterone only, depending on the option your doctor thinks is best for you.

Tranexamic acid

If you prefer a non-hormonal treatment, tranexamic acid is a great choice. It’s used to treat and prevent excessive blood loss by stabilizing blood clots and preventing them from breaking down prematurely. 

Ablation

Endometrial ablation works by using energy like radio waves, cold, or heat to destroy a thin layer of the endometrium. This action stops or significantly reduces monthly bleeding by getting rid of the tissue that sheds during your period. Although it’s considered a minimally invasive procedure, ablation is typically only used on women who don’t plan on having children and haven’t found success with other medications or treatments. 

Hysterectomy

A hysterectomy is a surgical procedure to remove the uterus. Due to the procedure’s definitive nature, it’s generally the last treatment option offered. With a hysterectomy, you will no longer menstruate, but there is a significant recovery period of four to six weeks. If your doctor chooses to remove your ovaries as well, it will induce immediate menopause, but even if the ovaries are left intact, the procedure accelerates menopause. 

Natural management strategies and supplements

If you’re not ready to try medical treatments, there are natural remedies you can use. 

Supplements

Heavy bleeding during menstruation can lower your ferritin levels and deplete your body’s iron stores. The result is an iron deficiency, where you can experience dizziness, headaches, and extreme fatigue. Iron supplements can help improve iron levels and make you feel better. Vitamin C helps improve iron absorption, making your supplement more effective. To help with cramping, painful periods, and mood, magnesium is a great choice. 

Diet

Eating an anti-inflammatory diet helps reduce inflammation that causes tissue damage and bleeding, provides hormonal support, and introduces plenty of protein and iron-rich foods to help you avoid anemia. Some women use seed cycling for additional nutrient support, which involves eating specific seeds throughout the menstrual cycle for hormonal support. 

For women who need additional support, Hormona is proud to offer an upcoming telemedicine service, where you can speak with medical professionals and receive personalized care. 

FAQs

Why won’t my period stop during perimenopause?

During the early and late stages of perimenopause, you will still get a period, but after 12 months without menstruating, you officially enter postmenopause. 

What is a dangerously heavy period?

Bleeding more than 80 ml is considered a dangerous amount, or the equivalent of bleeding through 1 pad per hour for 2+ hours. Additional symptoms include bleeding through double protection, needing to change protection during the night, bleeding for a week or more, passing blood clots larger than a quarter, and extreme fatigue.

Can heavy bleeding lead to other health issues?

Yes, heavy bleeding can lead to other issues, like low-iron anemia and extreme fatigue.